Provider Demographics
NPI:1326097890
Name:BOHANNAN, HOLLY (CRNA MSNA)
Entity Type:Individual
Prefix:
First Name:HOLLY
Middle Name:
Last Name:BOHANNAN
Suffix:
Gender:F
Credentials:CRNA MSNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18802 COPPERMINE RD
Mailing Address - Street 2:
Mailing Address - City:ROGERS
Mailing Address - State:AR
Mailing Address - Zip Code:72756-8148
Mailing Address - Country:US
Mailing Address - Phone:479-925-7882
Mailing Address - Fax:
Practice Address - Street 1:3000 MEDICAL CENTER PARKWAY
Practice Address - Street 2:
Practice Address - City:BENTONVILLE
Practice Address - State:AR
Practice Address - Zip Code:72712
Practice Address - Country:US
Practice Address - Phone:479-530-6649
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-10
Last Update Date:2010-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARR65511163W00000X
ARC02604 CRNA367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse